Download informed consent - St. Johns Lutheran Church and School, Mayville

St. John’s Athletic Opportunities
2014-2015 Academic Year
Name: ____________________________________________________ Grade: _______________
To help with planning for the upcoming seasons, please mark the sports you will be committed to
participating in during this school year:
_____ Volleyball (Fall)
_____ Cross-Country (Fall)
_____ Cross-Country (Fall)
_____ Soccer (Fall)
_____ Soccer (Fall)
_____ Basketball (Winter)
_____ Basketball (Winter)
_____ Spirit Squad (Winter)
_____ Spirit Squad (Winter)
_____ Softball (Spring)
_____ Softball (Spring)
CONSENT FOR ATHLETIC PARTICIPATION
St. John’s Lutheran School Athletics
Below is an acknowledgment that the students and parent(s)/guardian(s) have read and understand St. John’s
Athletic Handbook and are willing to abide by and support the aforementioned guidelines. Any situation that occurs
during a season that is not covered in the handbook will be acted upon at the discretion of the coach, athletic
director, and/or principal.
By signing below, you are stating that you:
1. Have read and understand the athletic guidelines and will support and abide them.
2. Understand that athletic programs are extracurricular activities and in order to participate, you (the student)
or your child must be working up to his/her potential in the classroom and meet basic academic and
behavioral requirements of his/her teachers.
3. Are award that you (the student) or your child may be suspended from those activities until the requirements
are met.
4. Agree to cooperate and support the coaches at St. John’s Lutheran School.
5. Wish to participate (the student) or wish your child to participate in St. John’s Interscholastic Athletics.
Student-Athlete Signature: ___________________________________________
Date: ___________________
Father Signature: __________________________________________________
Date: ___________________
Mother Signature: __________________________________________________
Date: ___________________
Legal Guardian Signature: ___________________________________________
Date: ___________________
INFORMED CONSENT
Awareness of Sports Injury Risk Warning & Agreement
2014-2015 Academic Year
By its very nature, competitive athletics can put students in situations in which SERIOUS, CATASTROPHIC,
and perhaps FATAL accidents could occur. Students and parents/guardians must assess the risks involved in
such participation and make their choice to participate in spite of those risks. No amount of instruction,
precaution or supervision will totally eliminate all risk of injury. Just as driving an automobile involves choice of
risk; participation in athletics is inherently dangerous. The obligation of parents and students in making this
choice to participate cannot be overstated.
By granting permission for your son/daughter to participate in athletic competition, a parent or guardian
acknowledges that playing or practicing in any sport can be a dangerous activity involving MANY RISKS OF
INJURY. Both the athlete and the parent must understand that the dangers and risks of playing or practicing to
play, include but are not limited to – death, complete or partial paralysis, brain damage, serious injury to
virtually all internal organs, bones, joints, ligaments, muscles, tendons, and other aspects of the skeletal
system and potential impairment to other aspects of the body, general health and well being.
Because of the dangers in participating in sports, we (parent/guardian and player) recognize the importance of
following coaches’ instructions regarding playing techniques, training, equipment, and other team rules, etc.
both in competition and practice and agree to such instructions.
If any of the preceding is not completely understood and you have questions, please contact the school.
I have read and understand the information above and give my son/daughter permission to participate in St.
John’s Lutheran School Athletic Programs.
Athlete’s Full Name (Please Print): _______________________________________________ Grade: ______
Athlete’s Signature: ________________________________________________ Date: __________________
Parent/Guardian’s Signature: ________________________________________ Date: __________________
RELEASE AND AFFIRMATION
We hereby affirm that we are aware of the inherent risks and hazards of interscholastic athletics and by signing
this release certify that we are cognizant of those risks. We understand and agree that neither St. John’s
Lutheran Church/School nor any of its employees and agents may be held liable in any way for any
occurrence, including rescuer operations, in connections with athletics that may result in injury, death, or risks
in connection with related activities related thereto for any harm, injury, or damage which may befall me and
further to save and hold harmless the Church, School, and all persons associated therewith from any claims by
us, or our families, estates, heirs, or assigns out of the enrollment and participation in athletics.
This is to be signed by the students and his/her legal parents/guardians with their consent. We understand
that the terms herein are contractual and not mere recital, and that this has been signed freely and voluntarily.
It is the intent of the signers hereto to exempt and release St. John’s Lutheran Church/School and all of its
agents and derivative damage caused by anyone’s act, error, omission or negligence.
We have fully informed ourselves of the contents of this Release and Affirmation by reading and understanding
it before we signed it.
Mother (Please Print): ____________________________ Signature: ________________________________
Father (Please Print): _____________________________ Signature: ________________________________
Legal Guardian (Please Print): ______________________ Signature: ________________________________
Student (Please Print): ____________________________ Signature: ________________________________
Date Signed: __________________________________________
MEDICAL TREATMENT AND STUDENT INSURANCE STATEMENT
Student (Please Print): ____________________________
Birth Date: ____________________
Grade: _____
During school hours and all school events and activities, including all athletic events, first aid shall be administered
to an injured student by a representative of the school unless a physician or emergency medical personnel are
present; in the latter case, the physician or emergency medical personnel will render first aid. Coaches will have
Student Information Sheets with them at all practices and games.
If any injury occurs to a student at school during school hours or any school sponsored event or activity, and the
injury appears to be serious, the injured students will be conveyed to a doctor, hospital, or clinic for treatment. (If
possible…to the doctor or hospital preferred by the parent/guardian.) If the injury occurs off school premises at a
school event or activity, and the injury appears to be serious, medical treatment will be provided as is reasonably
available. If the injury appears serious, the injured student will be conveyed to a doctor, hospital, or clinic for
treatment. (If possible…to the doctor or hospital preferred by the parent/guardian.)
The coach(es), athletic director, or parents/guardians, if required, will determine transportation to a medical facility.
The parent of a student who incurs an injury which requires more than first aid will be notified as soon as practicable
after the injury occurs. In an emergency situation, this notification may not occur until after the student has been
conveyed to the appropriate doctor, hospital, or clinic for treatment.
We understand that St. John’s Lutheran Church/School does not carry any medical expenses insurance for
the benefit of any students who may be injured at school or while participating in a school sponsored event
or activity, including athletic events, and that St. John’s nor its employees and coaches assume any
responsibility for such expenses.
We have read and understand the procedure described above for the treatment of a student who may be injured at
any school event or activity. We consent to having our son/daughter participate in all school activities and events,
including athletic events, involving St. John’s under these conditions and authorize medical treatment of injuries
incurred by our child according to the procedure described above.
____________________________________________________________ ______________________________
Parent/Guardian Signature
Date
____________________________________________________________ ______________________________
Parent/Guardian Signature
Date
EMERGENCY NOTIFICATION
_________________________________
Mother/Guardian
_______________
Home Phone
_______________
Work Phone
_______________
Cell Phone
_________________________________
Father/Guardian
_______________
Home Phone
_______________
Work Phone
_______________
Cell Phone
PREFERENCES FOR EMERGENCY PROCEDURES
We are providing this information with the understanding that our
son/daughter may not necessarily be brought to these people and/or places.
Child’s Physician: ____________________________________
Phone Number: _______________________
Clinic’s Address (Please include street address and city):
____________________________________________________________________________________________
Emergency Care Hospital: _____________________________
Phone Number: _______________________
Hospital’s Address (Please include street address and city):
____________________________________________________________________________________________
ATHLETIC PERMIT
Academic Year: 2014-2015
Student Name: _______________________________________
Date of Birth: _________________________
Address: ____________________________________________________________________________________
City, State, Zip Code: __________________________________________________________________________
Family Physician: _____________________________________
Phone Number: _______________________
Name of Private Insurance Carrier(s): _____________________________________________________________
Policy Number(s): _____________________________________________________________________________
I, as a parent (or legal guardian), of the above named student, hereby give my permission for the above named
student to practice and compete and represent St. John’s Lutheran School in interscholastic sports excepting those
restricted on this sheet. I agree to be financially responsible for the safe return of all athletic equipment issued to
him/her. I further grant permission for my son/daughter, named above, to be given immediate emergency care in
case of injury as a result of athletic competition. I also grant permission for any medical records pertaining to the
health of the above named student to be made available as necessary to the proper school or medical personnel.
_______________________________________________________________
Signature
________________________
Date
St. John’s Lutheran School Transportation Liability Waiver
St. John’s Transportation Policy states “Transportation at St. John’s is done primarily through parent driven cars.
Student-athletes and their parent(s)/guardian(s) are responsible for finding their own ride to games and
practices. The athletic director and coaches are not expected to make transportation arrangements. Drivers
need to make sure they have adequate auto insurance and that each rider wears a seat belt. There is usually
no problem in finding rides, as we encourage parents and families to come to the games to watch.”
For parents/guardians who provide transportation to these events, they must be aware of the following:
- Where parents/guardians provide transportation to their son/daughter to or from an event, the
parents/guardians shall assume all resulting liability, and the church/school shall assume no liability.
- Where parents/guardians transport students other than their own to or from an event, the
parents/guardians shall assume all resulting liability, and the church/school shall assume no liability.
I have read the Athletic Transportation Policy and agree that I shall assume all liability for negligently caused
injuries resulting from the following situations:
Where I transport my son/daughter to or from an event
Where I transport other students to or from an event
I also agree that St. John’s shall assume no liability whatsoever for negligently caused injuries resulting from
the above situations or any other situation where contracted transportation is not being used to transport
athletes.
___________________________________________________________
Signature
_______________________
Date